Authors and Acknowledgments
This document was developed by the American Academy of Child and Adolescent Psychiatry's Task Force on Community Systems of Care for Children with Serious Emotional Disturbances.

Introduction
As states and governmental entities seek to control the increasing costs of Medicaid programs, many are moving towards implementation of managed care principles. However, managed care approaches are relatively new in mental health, and those that exist have been developed with adult and private sector populations in mind.

This document, developed by the American Academy of Child and Adolescent Psychiatry's Task Force on Community Systems of Care, is designed to assist decision-makers in selecting managed mental health care systems that can most effectively serve this population. It defines principles that should be inherent in high quality programs. We encourage decision-makers to request and evaluate prospective mental health systems' descriptions of their ability to incorporate these principles into their operations. Furthermore, their success at meeting these principles should be measured on an ongoing basis, with quality improvement programs implemented in response to the findings. It is essential that a managed mental health system be able to provide integrated, coordinated care for all children and adolescents with emotional and behavioral disturbances.

Effective intervention requires a comprehensive, culturally sensitive assessment that considers the child's and family's weaknesses, builds on their strengths, and facilitates services in the least restrictive environment possible. Early identification, early intervention, planning for the long-term, normalizing lifestyles, and enhancing family unity and capabilities promote a healthier quality of life for those served. By providing a full array of community-based services, care providers in partnership with the individual and family are able to customize plans to most effectively help the child and family reach their goals.

A significant number of children, adolescents, and their caregivers who are Medicaid- eligible have serious emotional disturbances. Serious emotional disturbance in children is defined by the Center for Mental Health Services as follows':

Children with a serious emotional disturbance are persons: from birth up to age 18; who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified with

DSM-111-R

, that resulted in functional impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities.

These disorders include any mental disorder (including those of biological etiology) listed in DSM-III-R or their ICD-9-CM equivalent (and subsequent revisions), with the exception of -R "V" codes, substance use, and developmental disorders, which are excluded, unless they co-occur with another diagnosable serious emotional disturbance. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects.

Functional impairment is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment. Children who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are included in this definition.

Their complex needs require intensive medical and mental health services, as well as services offered through education, child welfare, juvenile justice and other child-serving agencies. Effective intervention needs to include a full array of services in a community-based system of care (based on CASSP principles, see Appendix A). Providing a full continuum of services allows the care providers to customize the care plan to most effectively help the patient and family. Ensuring coordinated care and establishing communication and collaboration across disciplines and agencies can be challenging, and thus requires an investment of time and resources. However, coordinated, multi-agency, multidisciplinary services may also improve cost efficiency and facilitate improved functional outcomes.

It is essential that Medicaid care plans be patient- and family-centered. Patients and their families must be involved in the assessment and treatment processes in order to ensure their effective implementation. These programs also need to share responsibility for the community, including the development of programs that address and monitor success in the following areas: access, prevention, wellness, community acceptance/responsiveness and patient/family satisfaction. Ultimately, success in the latter will determine the consumer acceptability and financial viability of such programs.

As Medicaid programs move to managed care approaches, estimating costs and payment structures can be difficult. We strongly recommend the use of actuarial consultants who can demonstrate their competence in public sector financing and have developed or can develop sound data on the expected needs of the covered population.

We hope that you find this information helpful. If you have additional questions about selecting a managed care vendor for your Medicaid program or on the development of requests for proposals for managed care Medicaid mental health services, please contact the American Academy of Child and Adolescent Psychiatry.

Governance
Delivery systems involving a managed care vendor mandate that state Medicaid programs create a purchasing/regulatory authority to draft an RFP and monitor contract performance. This authority should include multiple child-serving state agencies, such as Health, Mental Health, Education, Juvenile Justice, and Child Welfare departments and agencies. The state Medicaid agency makes all final contract decisions.

RFP Items

The managed care vendor has an advisory board that includes public representatives, private purchasers, consumers, and state personnel. Such an advisory board can help advise and guide the managed care organization in its interactions with state/local service agencies as well as consumers.

The managed care vendor provides its articles of governance for review during the selection process. These articles must demonstrate the process of decision-making in the organization, lines of authority and responsibility, and how the organization's quality improvement plans influence the operation.

The managed care vendor demonstrates that it respects the family's rights. It recognizes the autonomy and reasonable authority of the family in deciding on appropriate treatment and services. Furthermore, the vendor demonstrates that the privacy of the family is protected within the requirements and limits of state and federal law.

The family has ample opportunity to appeal denial of services, and the vendor provides data on the number of appeals filed and their outcomes. The appeals procedure and mechanism should be readily provided to families upon enrollment and offered upon any adverse decision or upon request. The managed care vendor identifies a point or points of contact to facilitate the request. All appeals procedures should lead to state-level appeals at the level of the purchasing authority, if unresolved at lower levels. The purchasing authority will be the final arbiter of all such appeals.

A specialized benefit track is available for high service utilizers, with well-defined descriptions of when these benefits come into effect. A risk-adjusted subcapitation rate exists for this population.

The managed care vendor is responsible for delivering the necessary services through contractual agreements with all appropriate agencies. The division of responsibilities among agencies is well-defined and agreed to in writing by all parties. In order to assure quality of services, each agency will provide oversight of its area of responsibility and report the results of such oversight to the appropriate purchasing/regulatory authority.

The purchasing authority should determine or negotiate an equitable percentage of profits which the managed care vendor should reinvest in development of the service system, both in expansion of services as well as improvement in quality of services.

The managed care vendor clearly demonstrates its administrative costs for the plan in any proposal. The purchasing authority should develop a priori criteria and guidelines of reasonable levels of administrative overhead that are expected from prospective vendors, and should communicate these in RFPs.

The managed care vendor must not base any merit or performance bonuses for executives or providers on amount of care rendered or on denials of service.

Terms of contracts between managed care vendors and providers should be consistent with the professional codes of ethics of the different mental health disciplines practicing within those organizations.

Benefit Design
With appropriate structure and oversight of services, benefit limits are unnecessary. Resource allocation should be based on clinical protocols and criteria that ensure that patients and families receive services according to their unique needs.

RFP Items

The vendor has a mechanism in place to identify children and families who require special services and/or are historically or predictably will be high utilizers of multiple services.

The vendor is able to administer a flexible benefit design through a credentialed provider network capable of delivering specialized services unique to children with serious emotional disturbances.

The vendor agrees that members cannot be ejected or rejected from the benefit plan due to their clinical condition or level of service need without cause. In cases involving clinical cause, there exists a notification and review process by the appropriate agency. Members may be disenrolled from the plan if they no longer meet eligibility criteria for Medicaid coverage. (See Provider Support Services.)

Although there may be limitations in some regions concerning the number and types of services and providers available, the vendor must demonstrate that it can provide the maximum array of services that will comprise an efficient and comprehensive system with an appropriate provider network for such services. The following is a list of suggested program components, with acknowledgement that it is not all-inclusive:

The vendor must include benefits addressing the needs of children with defined conditions requiring specialty mental health services, such as substance abuse disorders, developmental disorders, eating disorders, and treatment resistant conditions.

The array of services the vendor provides addresses the mental health needs of the community and the covered population. The delivery of combined services (Medicaid-funded and state/local services) is often most efficient in addressing the multiple needs of Medicaid-eligible populations. We recommend the use of "pooled" or "blended" funding, combining multiple sources (Medicaid/federal, state, local, non-profit, etc.) to enable managed care providers to provide combined, "wrapped-around" services. The vendor must negotiate the process to access such funding, or the allocation and coordination of such funding, and services with other agencies or providers.

Benefit design should have balance between flexibility of enrollment for the family and ensuring commitment of 12 months minimum with enrollment trial period.

The vendor proposes a transition plan for members entering and leaving the plan that addresses the unique clinical needs of children and families that minimizes disruption to existing care and optimizes services.

The vendor proposes procedures to transition coverage for adult services for individuals being served who progress into adulthood.

Access to Services
Delivery systems should remove barriers that impede access to necessary services. Access standards must ensure access for all individuals. The state Medicaid program will establish access protocols for developmental, socio-economic, geographic, and cultural needs of children, families, and communities.

RFP Items

Access protocols take into consideration the developmental, socio-economic, and cultural needs of individuals, families, and communities.

The vendor establishes a 24-hour 800 number, staffed by live agents to provide the following services: crisis hotline, crisis referrals, routine service requests, and benefit certification. Vendor has available licensed clinicians for crisis calls and referrals.

The delivery system's organization is appropriate to the member populations, communities and regions. For example, rural and inner city sites, culturally-appropriate providers and sites, and providers/services outstationed in schools, community centers, and welfare offices may be appropriate and necessary.

Children and families have access to early intervention, prevention, family peer support, and advocacy services.

Emergency services are available at service sites or by direct deployment, and emergency professionals have appropriate training and credentials for serving children and families in crisis.

Services are logistically convenient to the child and family, taking into consideration the geography, public transportation, and availability of social services.

The benefit allows for direct access to mental health professionals by patient/family self-referral, as well as through a primary care practitioner through customer-friendly procedures using the 800 number. There are appropriate communication linkages and coordination among primary care and mental health providers.

Care Plan Development
Care plan development represents the core of treatment delivery. The state Medicaid program establishes principles and guidelines for treatment plan development that considers interagency responsibilities, coordination, and integration of services and documentation requirements.

RFP Items

The vendor identifies children and families who require time-limited, less intensive services. The initial care plan is developed by a licensed mental health professional in consultation with a child and adolescent psychiatrist or psychiatrist with significant experience working with children and youth.

The vendor demonstrates a commitment to utilizing an inter-disciplinary team for care plan development. The initial care plan is developed by the inter-disciplinary team, including all relevant child mental health and child service professionals. A child and adolescent psychiatrist, psychologist, social worker, psychiatric nurse, and other members of the team should be involved in this initial development. The parent(s), other relevant family members, and the child, if appropriate, should be members of this team. The plan identifies the coordinator of services.

The plan identifies problem areas and deficits of function that prevent the child and family from functioning independently and appropriately, and it identifies interventions to address these problems and the discipline, professional, or agency responsible for each intervention.

The plan details and supports the child's and family's strengths and skills.

The vendor establishes a process and procedures to review the care plan. The plan is reviewed and modified on a regular basis, at a frequency proportional to the intensity and restrictiveness of the level of care, in order to facilitate effective case management.

Care plans are individualized to the needs of the child and family, including attention to cultural issues, and they are recorded in a unified form that follows the child throughout service delivery.

To the best of their capabilities, the patient/family are equal participants with the clinical team in the implementation of the plan of care.

The plan of care includes continuous communication and integration of all applicable services and agencies that have responsibilities for providing services to the child and family (such as primary care, juvenile justice, schools, and social services).

The needs of other family members are identified, and appropriate services are coordinated with their providers.

Physical health needs of family members are addressed and coordinated with the primary care provider.

The plan of care includes the integration of all services and agencies with responsibilities for providing services to the child and family (e.g., juvenile justice, schools, and social services, and primary care medical professionals), with safeguards to prevent single agency services unless indicated.

The vendor provides criteria for limited and extended therapeutic contacts and appropriate care planning for each.

A triage system exists with established guidelines for directing children and families to services and providers appropriate to their special needs.

The vendor provides a list of the credentials and licenses of all staff who provide triage services. These staff have experience and training specific to their assigned responsibilities and to the developmental needs of children and their families, including both child health care and mental health care.

A child and adolescent psychiatrist, psychologist, social worker, psychiatric nurse, and other members of the team must be involved in the development of triage procedures and protocols.

Mental health assessments are made only by licensed providers who are credentialed and trained to conduct assessments of the special needs of children. The vendor justifies that these providers are qualified to meet these special needs.

The comprehensive assessment includes:

Relevant information obtained from all other child services agencies that historically have been or currently are involved with the child and family, with the family's consent.

Assessment of functioning of the child in regard to:

School/education

Family

Peer group

Community/culture

Mental/physical health (including diagnoses and biopsychosocial status and communication with the primary care physician to ascertain the child's medical vulnerabilities.)

The parent(s), family, and/or pertinent caregiver as an active parts of the assessment process.

Standardized measures should be utilized whenever appropriate. These should be reliable, valid, clinically useful, culturally competent to the population being served, and useful for programmatic evaluation.

Treatment and other services are specific to the unique needs of children and their families, and particularly to the needs of seriously emotionally disturbed children and their families.

Goals developed from the assessment are focused and measurable. Assessment of the above dimensions should include both standardized, quantitative measures and individualized, qualitative measures. Standardized measures should be selected on the basis of reliability, validity, clinical utility, programmatic feedback utility, and cultural competence/appropriateness to the population being served.

The results of the child's evaluation and treatment plan and ongoing information in response to treatment are provided regularly to the primary care physician to facilitate coordination of care.

Child and adolescent psychiatrists, psychologists, social workers, psychiatric nurses, and other members of the team participate in the development of service protocols to ensure that the special developmental, physical, mental, and emotional needs of the child are addressed.

The system should have available expertise in as many diverse therapeutic modalities with children and families as possible, particularly in those that have demonstrated effectiveness with seriously emotionally disturbed children. These include, but are not limited to, the following:

Pharmacotherapy

Family therapy

Cognitive-behavioral and behavioral therapies (individual and group)

Psychodynamic therapies (individual and group)

Parent training or other educational interventions

Activity therapies

Occupational therapy

Culturally syntonic or traditional modalities

Environmental interventions

Home-based therapies

Case management

The AACAP's Criteria on Levels-of-Care should be utilized in determining the appropriate intensity, restrictiveness, and level of care to be provided for the child.

The vendor should have providers with appropriate training, skills, and experience appropriate to the age spectrum and psychiatric disorders disorders encountered in the covered population. This should include providers with specialty expertise in defined psychiatric conditions in childhood or adolescence.

Professional qualifications to implement any such modalities are based on training specifications and maintained in the systems' credentialling files.

The vendor describes in detail how it will address treatment mandates from Juvenile Justice, Child Welfare, Special Education, courts, and other agencies, including how these service needs will be integrated into the care plan. A formal mechanism is available to appeal disagreements on the necessity of such mandated services, which is negotiated a priori with the relevant public agencies.

Trainees in terminal programs in child mental health disciplines are allowed to be credentialed as providers, as long as they provide care as part of a training program that is fully credentialed and under the direct supervision of appropriate, credentialed, licensed faculty. Direct supervision implies the identification of the specific responsible faculty supervisor involved in the services provided to a child and family, but does not require continual live observation of services rendered.

High Utilizers' Track:

Criteria for access to the high utilizer track should be well-defined and based at least on functional impairment as influenced by support systems and risk factors. Such criteria should be independent of assigned diagnosis.

Children in this track should be documented to have or be at risk for chronic, persistent disturbances. Benefits in this track should include long-term case management and continuous clinical follow-up services, as well as intermittent acute services at times of crisis or developmental change.

The service team is multi-disciplinary and multi-agency and includes the family and patient, as much as possible. Care plans address short-term as well as long-term treatment and rehabilitative needs.

Fiscal and service responsibilities are well-defined among the various participating agencies and service providers, including primary care.

This track has maximum flexibility for assigning children to different levels of care and support. There is also an allowance for wrap-around approaches to supplement care plans with other necessary services.

Rehabilitative services are an integral component of this track, maximizing utilization of available educational and vocational services offered through public agencies, as well as other supplements dictated by the child's and family's needs. Such services should address practical daily living, employment, and social skills.

Older patients on this track have a transition plan to adult services to ensure continuity, as well as the necessary intensity of services beyond age 2 1. Such a transition plan must include the transfer of the active care plan, the continuation of needed treatment services, and the continuation of intensive and extensive case management.

Special protocols are developed within this track to address the unique needs of highly resistant or difficult to serve, multi-problem children and families. The protocols should include strong inter-agency coordination, demonstrated access to culturally competent consultation and interventions, and review of services utilized with these children and families to identify more effective interventions.

Case Management
Case management involves the coordination and integration of a complex matrix of treatment services designed to optimize care and services for children and families.

RFP Items

Case management services are provided (e.g. assessment of problem areas, measurement of functioning level, determination of needs, linkage with necessary resources, care coordination, advocacy, and monitoring of services provided and their outcomes). The frequency and intensity of case management services will be proportional to the clinical and psychosocial needs of the child and family.

Continuous case management specific to the unique needs of children with serious emotional disturbances and their families will be provided, in most cases throughout the child's enrollment in the vendor's plan.

The vendor provides a list of the credentials and licenses of all staff who provide case management services. These staff have experience and training specific to both the developmental needs of children and their families and their assigned responsibilities. Such licensed, credentialed staff may supervise unlicensed staff in providing defined case management services which do not require direct involvement by licensed staff.

The patient/family are participants in the case management process, with shared responsibility with case managers for utilizing and coordinating services.

Child and adolescent psychiatrists, psychologists, social workers, psychiatric nurses, and other members of the team should participate in the development of case management protocols to ensure that the child's comprehensive developmental, physical, and mental/emotional needs are addressed.

Case management protocols should facilitate the coordination of multi-agency, multi-system interventions, integrating service from the various providers and agencies responsible for serving the child, and ensure coordination of services with primary care physicians and health providers.

Quality Assurance/Improvement
The key to a health care delivery system is its quality assurance/improvement program. Quality management programs provide structure and direction while the associated activities provide information on how well individual providers, service entities, and service delivery systems are achieving their goals and objectives. The state Medicaid program establishes minimum quality standards and performance measures to assist child-serving state agencies in their monitoring of a managed care vendor and the services it provides.

The managed care vendor must provide a detailed plan for quality improvement and utilization review. Such a plan must include the following:

There is periodic measurement, reporting, and analysis of well-defined indicators of service quality, including surveys of patient/family satisfaction with various aspects of the program. The RFP should specify a minimum number of quality improvement studies and indicators, with the vendor then adding further recommendations in their proposal. Areas of negative outcomes and delivery of inappropriate treatment are particularly important areas to focus on.

There is periodic assessment of clinical and functional outcome. Vendors describe in detail what methods and tools they will use and why.

Vendors must demonstrate the ability to practice continuous quality improvement in their delivery systems and their components. Additional areas for monitoring should be identified through both customer surveys and quality indicators with proven efficacy. They should result in study using total quality management processes and tools by teams of system staff and consumers, with interventions and resulting outcomes measured systematically.

The RFP should specify a minimum set of credentialling standards for providers under the plan, including credentials for child mental health providers. Training in cultural competence, applicable to the culturally diverse populations being served, should be part of minimum credentials.

The vendor should provide a list of the credentials, licenses and special qualifications of all staff who provide treatment services. These staff must have experience and training specific to their assigned tasks and to the developmental needs of children and their families.

The vendor provides criteria for provider enrollment into the plan or network as well as criteria for provider termination or de-listing. These criteria must be related to quality assurance/improvement and credentials monitoring.

The vendor provides a list of de-listed provider or services and the rationale for de-listing from the plan/network. All de-listed providers or services must be provided with this rationale and with an appeals procedure for such action.

Child and adolescent psychiatrists, psychologists, social workers, psychiatric nurses, and other members of the team should be involved in the development of continuous quality improvement protocols, including those required in the RFP's.

Providers, facilities and agencies receive timely enrollment and disenrollment information. A pool of money is available to pay for services that are given by providers in good faith to individuals later found to be disenrolled.

A pool of money is available to pay for emergency services when the managed care vendor is not available for pre-authorization.

The division of responsibilities among clinicians and other providers of services, including services provided as part of the general health versus mental health benefit, is well-defined and agreed to by all parties.

The attending clinician and/or treatment team leader is notified of requests for emergency and/or protective services in a timely fashion.

The division of responsibilities among state health and human services agencies providing services to the Medicaid-eligible population is well defined through inter-agency memoranda of agreements or legislative provisos. Such agreements need to delineate access procedures for mandated services outside the scope of the plan.

The purchasing authority provides timely access to mandated health and human services and other necessary support services. An appeal mechanism is available when access is not timely.

The managed care vendor supports the providers' efforts to maintain continuity of care when there is a change in the contract or patient eligibility.

The managed care vendor provides a mechanism for dealing with members whose behavior is disruptive to the treatment process (e.g. threatening or abusive behavior, demands for medically unnecessary services, and failure to keep appointments and/or total refusal to participate in treatment planning or services). This must include specialized support programs to address the needs of such members and their families.

The managed care vendor provides appropriate medical diagnostic and pharmacy services for the child's mental illness, either through the plan or in coordination with the general health plan(s).

While protecting patient confidentiality, the various agencies involved will make utilization data available to the managed care vendor for determining service needs, prevalence of illness, and financial risk.

The vendor/provider should be notified by any public emergency services providers prior to any decisions to render services, especially prior to hospitalization.

The vendor must be notified if a covered child is being considered for special educational services well before the EEP meeting to coordinate services with schools.

Information Management
Collecting and reporting of key data is critical to monitoring and evaluating quality and outcome performance. The state Medicaid program establishes minimum reporting requirements. Reporting requirements should include administrative and clinical measures.

RFP Items

The managed care vendor's MIS should have design flexibility to accommodate database linkages and the reporting requirements associated with Medicaid populations. The vendor demonstrates the capacity to determine clinical outcomes, costs, and quality indicators from its management information system (MIS).

The MIS should be based on the system's clinical database, which derives its information from defined fields in the clinical record format.

The managed care vendor demonstrates how confidentiality is protected in the face of information system and communication needs. Policies are in place for both aggregate and individual patient information and include descriptions of how the patient's and family's assent and consent are obtained, particularly with respect to adolescents and others at appropriate functional and developmental levels. Furthermore, these policies comply with the state's legislation regarding confidentiality, while still encouraging multi-agency communication.

A single, unified clinical record should include an individualized treatment plan that actively reflects continuous coordination across all agencies and providers delivering services. This means that the clinical record follows the patient throughout the service system and is not segmented by provider or episodes of care. Policies for different frequencies and intensities of documentation at different levels of care should be developed within this unified clinical record.

The individual unified clinical record should include the use of quantitative and qualitative assessment measures, standardized measures of clinical and functional outcome, and measures of the effectiveness of implementation of therapeutic interventions, as well as compliance with them by clients and families.

The vendor must maintain a comprehensive unified clinical database on all patients or members it has served, with data fields based on the content of the unified clinical record. This database should be well-defined and contain de-identified information to assist in cost analysis, outcome evaluation, and quality assessment and improvement activities.

The managed care vendor will utilize data from federal and state health and human service agencies, available relevant epidemiological studies, and other available data sources (including studies it may choose to conduct and its own database) to develop prevalence estimates on behavioral illness and service need in the plan membership in order to develop an appropriate risk adjustment.

The governing authority, or consultants it may designate, should have access to aggregate datasets of the vendor's database in order to monitor contract performance and to study services utilization trends for the purpose of public policy development.

Emotionally disturbed children should have access to a comprehensive array of services that address the child's physical, emotional, social and educational needs.

Emotionally disturbed children should receive individualized services in accordance with the unique needs and potentials of each child, and guided by an individualized service plan.

Emotionally disturbed children should receive services within the least restrictive, most normative environment that is clinically appropriate.

The families and surrogate families of emotionally disturbed children should be full participants in all aspects of the planning and delivery of services.

Emotionally disturbed children should receive services that are integrated, with linkages between child-caring agencies and programs and mechanisms for planning, developing and coordinating services.

Emotionally disturbed children should be provided with case management or similar mechanisms to ensure that multiple services are delivered in a coordinated and therapeutic manner, and that they can move through the system of services in accordance with their changing needs.

Early identification and intervention for children with emotional problems should be promoted by the system of care in order to enhance the likelihood of positive outcomes.

Emotionally disturbed children should be ensured smooth transitions to the adult service system as they reach maturity.

The rights of emotionally disturbed children should be protected, and effective advocacy efforts for emotionally disturbed children and youth should be promoted.

Emotionally disturbed children should receive services without regard to race, religion, national origin, sex, physical disability or other characteristics, and services should be sensitive and responsive to cultural differences and special needs.